A nurse is contributing to the care plan of an older adult client who has pneumonia. Which of the following interventions should the nurse include in the plan?
Encourage fluid intake of 2.5 L per day.
Assist the client to cough and deep breathe every 4 hr.
Encourage independence in completing ADLs.
Use an N-95 respirator when providing client care.
The Correct Answer is A
A. Encourage fluid intake of 2.5 L per day.
This is an appropriate intervention for a client with pneumonia. Increasing fluid intake helps to thin respiratory secretions, making them easier to cough up and clear from the airways. Adequate hydration also supports overall health and immune function. However, the nurse should consider the client's individual fluid tolerance and any comorbid conditions such as heart failure that may necessitate fluid restriction.
B. Assist the client to cough and deep breathe every 4 hr.
This intervention is also appropriate for a client with pneumonia. Coughing and deep breathing exercises help to mobilize and clear respiratory secretions, preventing complications such as atelectasis and pneumonia. However, the frequency of coughing and deep breathing may need to be tailored to the client's tolerance and respiratory status.
C. Encourage independence in completing ADLs.
While promoting independence in activities of daily living (ADLs) is generally beneficial for older adult clients, in the context of pneumonia, the priority is to ensure adequate rest and conserve energy for recovery. Depending on the severity of the illness, the client may experience fatigue and dyspnea, making it challenging to perform ADLs independently. The nurse should assess the client's functional status and provide assistance as needed while promoting independence to the extent possible.
D. Use an N-95 respirator when providing client care.
This intervention is not directly relevant to the care plan for a client with pneumonia. N-95 respirators are primarily used for respiratory protection against airborne infectious agents such as tuberculosis or certain viral infections like COVID-19. While standard precautions should be followed when caring for a client with pneumonia to prevent the spread of infection, including hand hygiene and appropriate use of personal protective equipment (PPE), an N-95 respirator is not typically indicated unless the client has a specific respiratory pathogen requiring airborne precautions.
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Related Questions
Correct Answer is D
Explanation
A. Auscultate breath sounds at least every 2 hours.
Regularly auscultating breath sounds is important for assessing respiratory status and detecting any signs of respiratory complications such as pneumonia or atelectasis. However, it is not the priority action in this scenario compared to applying antiembolic stockings, which directly addresses the increased risk of DVT and PE associated with immobility.
B. Perform range-of-motion exercises at least two to three times daily.
Range-of-motion exercises help prevent contractures and maintain joint mobility in immobile clients. While they are important for preventing musculoskeletal complications, they are not the priority action compared to applying antiembolic stockings, which directly addresses the increased risk of DVT and PE associated with immobility.
C. Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day.
Maintaining adequate hydration is important for overall health and prevention of complications such as urinary tract infections and constipation. However, it is not the priority action in this scenario compared to applying antiembolic stockings, which directly addresses the increased risk of DVT and PE associated with immobility.
D. Apply antiembolic stockings.
The priority action for the nurse to contribute to the plan of care for an immobile client is to apply antiembolic stockings. Immobility increases the risk of deep vein thrombosis (DVT) and subsequent pulmonary embolism (PE). Antiembolic stockings (also known as compression stockings or TED stockings) help prevent venous stasis and decrease the risk of blood clots forming in the lower extremities. Therefore, applying antiembolic stockings is essential in mitigating the risk of potentially life-threatening complications associated with immobility.
Correct Answer is B
Explanation
A. Prone with arms raised over the head.
This position involves lying face down with the arms raised over the head. It is not appropriate for thoracentesis because it does not provide easy access to the thoracic cavity, and it may compress the chest, making it difficult for the client to breathe comfortably during the procedure.
B. Sitting, leaning forward over the bedside table.
This is the correct choice. For thoracentesis, the client should be positioned sitting upright and leaning forward over the bedside table or supported by pillows. This position allows better access to the thoracic cavity and facilitates the removal of pleural fluid. Leaning forward also helps to open up the intercostal spaces, making it easier for the healthcare provider to insert the needle into the appropriate space between the ribs.
C. High Fowler's position.
The High Fowler's position involves the client sitting upright with the head of the bed elevated at a 90-degree angle. While this position may be used for other respiratory procedures or for comfort, it is not the optimal position for thoracentesis. It does not provide the same degree of access to the thoracic cavity as the sitting position with forward leaning.
D. Side-lying with knees drawn up to the chest.
This position involves lying on one side with the knees drawn up to the chest. It is not appropriate for thoracentesis because it does not provide access to the thoracic cavity, and it may obstruct the procedure. Additionally, this position may not be comfortable for the client during the procedure.
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